● Legal Document

Telehealth Consent & Terms of Service

Wellness Institute for Sleep and Health, PLLC (“WISH”) — WISH Weight Management program. Questions? [email protected]

Please read this document carefully before completing your intake form. By checking the consent box in the intake form, you acknowledge that you have read and understand these terms. The intake form captures your electronic signature and a timestamp of your acknowledgment.

1. Nature of the Service

WISH Weight Management is an asynchronous telemedicine service in which you submit health information via a secure online intake form. A licensed physician reviews your submission and, if clinically appropriate, issues a prescription for a compounded weight management medication without a real-time video or phone consultation. This is a cash-pay program. Insurance is not billed and no superbills are provided.

2. Telehealth Disclosure

This service uses asynchronous (store-and-forward) telehealth technology, which is authorized under Washington State law (RCW 18.134.010) and applicable laws in Oregon and Montana. By submitting this form, you consent to the use of electronic health information and asynchronous communication for the purpose of this clinical encounter. The prescribing physician is licensed in the state where you reside at the time of service.

3. Risks and Limitations of Asynchronous Telehealth

Asynchronous telemedicine has inherent limitations compared to an in-person visit. The prescribing physician has not physically examined you and relies entirely on the health information you provide. Risks include:

Failure to identify conditions not disclosed by you;
Delay in identifying conditions not captured by the intake form;
Inability to perform a physical examination, which may be clinically relevant.

This service is not appropriate for emergencies. If you experience a medical emergency, call 911 immediately.

4. Benefits and Risks of Compounded GLP-1 Medication

GLP-1 receptor agonist medications (including tirzepatide and semaglutide) are shown to produce clinically meaningful weight loss when combined with diet and exercise. Benefits may include: weight reduction, improvement in metabolic markers, and improvement in weight-related comorbidities including sleep apnea and blood pressure.

Risks include: nausea, vomiting, diarrhea, constipation, abdominal pain, injection site reactions, pancreatitis, gallbladder disease, and a theoretical risk of thyroid C-cell tumors (observed in rodents; human clinical significance unknown). Additional risks in patients with type 2 diabetes include hypoglycemia (particularly when combined with sulfonylureas or insulin) and potential transient worsening of diabetic retinopathy with rapid glucose correction.

Important Notice About Compounded Medications: The medication dispensed through this program is a compounded preparation from a licensed 503A compounding pharmacy. It is not the same as the FDA-approved brand-name medications (Zepbound, Mounjaro, Ozempic, or Wegovy). Compounded medications are not FDA-approved and have not been evaluated by the FDA for safety, efficacy, or quality. The 503A pharmacy prepares your medication based on a patient-specific prescription.

A comprehensive side effect guide is available at wishcares.org/weight-management/side-effects/.

5. No Guarantee of Results

WISH makes no guarantee, express or implied, regarding weight loss outcomes or the effectiveness of this treatment for any individual patient. Results vary significantly. Submission of this form does not guarantee a prescription; the physician may determine, after reviewing your intake, that this medication is not appropriate for you.

6. Patient Responsibility and Accuracy of Information

You are solely responsible for the accuracy and completeness of all information you provide in the intake form. Providing false, misleading, or incomplete information — including undisclosed diagnoses, medications, allergies, or contraindications — may result in serious harm including death. WISH relies on your self-reported information and cannot independently verify it. If your prescription is issued and you are subsequently found to have provided inaccurate information, your prescription may be cancelled without refund and you may be discharged from the program.

7. No Ongoing Physician-Patient Relationship

Each prescription issued through the WISH Weight Management program represents a discrete clinical encounter, not an ongoing physician-patient relationship. WISH is not your primary care provider, your mental health provider, or your emergency provider. If you require ongoing medical management, specialist evaluation, or mental health care, you must seek those services separately. You are advised to inform your primary care provider that you are participating in this program.

8. Prescription Fees and Refund Policy

Your payment information is collected at intake and charged only if a physician approves your prescription. If the reviewing physician determines that a prescription is not clinically appropriate, your card is never charged. If a refund is applicable, it will be returned to your original payment method within 5–7 business days.

No refunds are issued for prescriptions that have been dispensed and shipped from the pharmacy. Questions about shipping or product quality should be directed to the pharmacy or to WISH at [email protected].

9. Limitation of Liability

To the maximum extent permitted by applicable law, WISH, its officers, physicians, employees, contractors, and agents shall not be liable for any indirect, incidental, special, consequential, or punitive damages arising from your use of this service, including but not limited to adverse effects of medication, complications arising from treatment, or outcomes attributable to inaccurate or incomplete self-reported health information. WISH’s total liability for any claim arising from this service shall not exceed the total amount paid by you for the specific prescription giving rise to the claim.

10. Dispute Resolution

Any dispute arising out of or related to this agreement or your use of the WISH Weight Management service that cannot be resolved informally shall be submitted to binding arbitration administered by JAMS under its applicable rules, before a single arbitrator, in King County, Washington. Judgment on the award may be entered in any court of competent jurisdiction. Nothing in this clause prevents you from filing a complaint with the Washington Medical Commission, Oregon Medical Board, or Montana Board of Medical Examiners, or any applicable state or federal regulatory body.

11. Privacy and Washington My Health My Data Act

Your health information will be collected, stored, and used in accordance with HIPAA and, for Washington state residents, the Washington My Health My Data Act (RCW 19.373). Your consumer health data will not be sold or disclosed to third parties except as necessary for treatment (pharmacy), payment processing (Stripe), or as required by law. A full Privacy Notice is available at wishcares.org/policies.

12. Communications Consent

By submitting this form, you consent to receive email communications from WISH regarding your prescription status, order updates, and program information. You may opt out of marketing communications at any time by contacting [email protected].

Your electronic consent is captured by checking the acknowledgment box in the intake form, which records your name, a timestamp, and your IP address.

By checking the consent checkbox in the intake form, you affirm that you have read and understood this entire document and agree to its terms in their entirety.

Questions about this document? [email protected]
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